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A History of YALE'S SCHOOL OF MEDICINE

YALE UNIVERSITY PRESS

Chapter One

Several important themes have tended to recur throughout the rich history of the Yale University School of Medicine since it was chartered as the Medical Institution of Yale College nearly two hundred years ago, in 1810. First and foremost among these themes has been the close relationship between the university and the medical school from its inception. Most medical schools in the United States were founded as private proprietary schools, which were subsequently subsumed by a university; Cooper Medical College, for example, became the Stanford University School of Medicine. The Medical Institution, in contrast, was founded by the Yale Corporation. As a result, the culture of Yale College fashioned the ethos of the medical school. Success in science was fostered from the beginning. Benjamin Silliman, who was appointed professor of chemistry and natural history in 1802, played a key role in the founding of the Medical Institution. Russell Chittenden, director of the Sheffield Scientific School, played a similarly influential role in the medical school seventy-five years later. Partly as a result of this basic emphasis on science, clinical medicine has never assumed the importance at Yale that it did at other medical schools.

The religious origins of Yale College have played a special role in its relationship with the medical school. Education was basic to the Puritan outlook. The desire for a university with lectures in medicine and law, first put forward at Yale by President Ezra Stiles in 1778, was a clear expression of Puritanism. Cotton Mather, one of the leading Puritan divines in New England, talked of the need to heal the body as well as the soul. Persistence of what Mather called the "Angelical Conjunction" is a plausible explanation for why the Yale Corporation has rescued the medical school on a number of occasions from a "near-death experience," when the prudent course of action would have been to let it expire.

Another legacy of university influence on the medical school at Yale has been an unswerving commitment to excellence on the part of the medical faculty. During the latter part of the nineteenth century, medicine had entered a dark period. The public rightly distrusted doctors and medical practice. Alternative medicine was flourishing, and enrollment in legitimate medical schools was decreasing as proprietary schools churned out inadequately trained doctors. In the midst of this turmoil, the faculty of the Medical Institution of Yale College continued to raise standards, with a resulting drop in medical-student enrollment. Because faculty salaries depended on fees from students, the more the faculty members elevated standards, the less remuneration they received.

Chronic underfunding has been the major reason for the recurrent threat of medical-school extinction. During the early years of the medical school, Yale College had financial problems, and available funds were committed to the undergraduate experience. Although the close relationship with the university played an important role in the success of the medical school, Yale College was clearly the center of attention. Not until the 1960s, with increased research funding and clinical income, did the medical school become a revenue-generating institution. Money has always played an important role in the life of the school, as it has at every academic institution. In the course of the medical school's history, there have been good medical-school deans and bad ones, good university presidents and bad ones, but if funds were plentiful, a lot of problems were either solved or covered over.

National events also played an important role in the success of the medical school. Abraham Flexner was commissioned to review the nation's medical schools. Flexner's assessment in 1910 that Yale and Harvard were the only two medical schools in New England worth keeping was instrumental in continuing the Yale Corporation's support of the medical school. Similarly, the federal decision to support research at universities after World War II helped the medical school eliminate a chronic deficit that threatened its future.

In addition to national influences, local influences played an important role in shaping the medical school. The Medical Institution of Yale College was founded as a joint effort of the college and the Connecticut Medical Society, which may have helped prevent the kind of proliferation of medical schools in Connecticut that occurred in neighboring states. The State Hospital was founded in New Haven by local physicians and Yale's medical faculty. Implementation of the full-time clinical system in return for Rockefeller Foundation support estranged the community physicians and led to the flourishing of the Hospital of Saint Raphael and the Grace Hospital in New Haven. Later, the presence of well-trained community physicians also contributed to the lack of emphasis on clinical areas within the medical school.

The "Yale system" of medical education, which does not assign or recommend particular texts but emphasizes intellectual freedom and has a research-thesis requirement, has been a recurrent theme for the past seventy-five years. Yale medical students do not in fact have more free time than students at other schools and may even have less than some. The perception, however, that faculty members are interested in students having more freedom results in most, although not all, medical students seeming less stressed. Critics have remarked that treating the medical students like graduate students may be a response to a lack of clinical material in New Haven rather than a new educational thrust. Be that as it may, Yale medical students continue to enjoy the Yale system.

The Medical Institution of Yale College opened its doors in 1813. To appreciate the impact of the Medical Institution, however, we need to bear in mind the effect of the founding of Yale College in 1701 on medical care in the colonies. The fact that the charter to grant M.D. degrees in addition to licensing physicians had been given to the Connecticut Medical Society meant that the university had to share control of the medical school. Hence, the use of the word institution rather than department, which would have implied total university control. The importance of a strong beginning for the medical school was recognized by Yale College, and the recruitment of Nathan Smith as the founding professor, paired with Benjamin Silliman, guaranteed that strength.

Nathan Smith's death in 1829, the opening of competing medical schools, and a general disillusionment with medicine resulted in a dark period of Yale medicine until the 1880s. The college was almost totally disengaged from the medical school and did not deign even to answer faculty pleas for help. Toward the latter part of the nineteenth century, science began to flourish on the Yale College campus after the formation of the Sheffield Scientific School in 1861. Some of this scientific excellence began to permeate the medical school, but something more had to happen or the school would fade from the scene.

And something did happen. In 1910 the Carnegie Foundation for the Advancement of Teaching commissioned Abraham Flexner to review medical education in the United States. After completing the Carnegie report, Flexner joined the Rockefeller Foundation to implement improvements in medical education in the United States. Convinced that full-time clinical practice was the solution, he offered financial support to Yale if it would move to a full-time clinical system. Such a move required academic control of the New Haven Hospital, and the new dean, George Blumer, set out to accomplish the task, which involved raising funds for the hospital. The faculty members were willing to support the change, but the community physicians were adamantly opposed to it.

Dean Blumer made several key appointments during his decade-long tenure, including his successor, Milton C. Winternitz, as professor of pathology and C.-E. A. Winslow as professor of public health. Winternitz, a product of Johns Hopkins, succeeded Blumer as dean with incredible energy. Scientific medicine was introduced with his recruitment of Francis Blake and John Peters to the Department of Medicine. He championed the Yale system and fostered the concept of social medicine with the formation of the Institute of Human Relations. Capitalizing on the base that Blumer built, Winternitz was able to garner university funds for buildings and professorships. A complex personality who was either loved or hated, he was involved in everything. But after fifteen years, the department chairmen had had enough, and Winternitz's term as dean was not renewed.

The next fifteen years were quiet ones for the school, although not for the world. During the height of the Depression, the medical school tried to grapple with social responsibility, led by John Peters, a forceful proponent. The Depression ended with World War II, which involved the medical school more completely than did any other war. The majority of the students were in military programs, and medical education was accelerated-to no one's satisfaction. The five years following the war were spent reintegrating students, graduates, and faculty into a normal medical-school routine. Finances were again a problem. The school was running a chronic deficit, and President Charles Seymour warned that the university could not continue to support the medical school forever.

A federal decision to support basic research in universities did much to restore financial health to the medical school. The appointment of Vernon Lippard in 1952 as the first full-time dean with connections to foundations was also important for the medical school's success. Funds became available to recruit outstanding individuals like Paul Beeson as chairman of the Department of Medicine, who in turn recruited excellent young faculty. This was the period during which the medical school rose to international prominence.

Facilities were expanded to keep pace with the growth in faculty size. One of the most important additions had already occurred in 1939 with the construction of the Medical Library. The Medical Library at Yale is not merely a place that houses books and journals but is truly the soul of the medical school. It offers a supportive ambience of scholarship that embraces the individual.

Vernon Lippard stepped aside in 1967, just in time to escape the rising social unrest that pervaded the country, the city, the university, and the medical school. Success of the Yale system depended on teachers teaching and students studying. The turmoil caused by anti-Vietnam War sentiment and the civil rights movement severely threatened the integrity of the program. Medical students and faculty were going in different directions. The community made its unhappiness with the medical school and hospital forcefully known. Nevertheless, the institution held together.

The medical school is composed of departments, which act relatively independently. The Department of Medicine is the largest department, with research funding equal to that of all the basic science departments together. Starting with Nathan Smith, the department consisted of a single professor until the 1920s, when Francis Gilman Blake was appointed chairman in 1921. He brought with him John Punnett Peters, a giant in American medicine who made laboratory medicine clinically relevant. The appointment of Paul Beeson in the 1950s, and the faculty he recruited, brought the department national prominence.

In a similar vein, the appointment of C.-E. A. Winslow in 1915 had heralded the beginning of a major concentration on public health. His determination to make public health a part of the medical school has persisted, but with difficulty. The department is named Epidemiology and Public Health, reflecting the conflict between Winslow and John Peters, who was in favor of studying disease rather than promoting health, a conflict that continues to this day.

This overview of the medical school's history will I hope set the scene for a more careful look at the events that formed the Yale University School of Medicine and its relationship to its parent university. We shall also need to bear in mind the role that Yale College played in the practice of medicine in Connecticut before the founding of the Medical Institution of Yale College in 1810.

(Continues...)

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Excerpted from A History of YALE'S SCHOOL OF MEDICINE by GERARD N. BURROW Copyright © 2002 by Yale University. Excerpted by permission.
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